I just received the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Mental health practitioners have been awaiting this book for years. Having been out for less than a month, the book has already received two and a half stars on Amazon. At first, I thought it funny that a book like the DSM would be rated at all; the DSM is the only option available for diagnosing “mental disorders,” and in some ways it is odd to assign such a book a rating. Alas, this new diagnostic manual has left many people unhappy. Reviews of the DSM-5 reveal a very basic fact about the practice of diagnosing conditions of the mind: people love and hate labels. Okay, yes, you’re right. Nothing is that simple. I don’t even fall into either of those categories. Labels are like everything else in life; they have both advantages and disadvantages. Labels can be like chains; some people pathologically embrace labels to the extent that they cannot behave outside of the expectation of that label. For instance, a person who labels himself as “unforgiving” may hold a grudge forever without considering the possibility that he may be capable of occasionally offering mercy. In another example, a person diagnosed with Bipolar Disorder may face seeming interrogation by loved ones every time she exhibits appropriate excitement, happiness, or productivity. On the other hand, people often find peace in having an explanation or label for their experiences. To know that emotional experiences, thoughts, sets of personality traits, or “symptoms” are so common that they have names can help some people feel a sense of belonging and connectedness (i.e., “I am not alone”). Diagnostic labels can also help inform treatment. For example, when somebody presents with symptoms that partially or fully meet criteria for a specific “mental disorder,” it provides an excellent starting point for therapeutic options. I do believe that it is important that clinicians consider the diagnosis a starting point in therapy. Certain techniques work well with depression, others with anxiety, and still others with Posttraumatic Stress Disorder (PTSD). With that being said, if recommended therapeutic interventions for depression do not appear to work, it is important to consider alternatives which may or may not have made the list of “evidence-based practices.” The other function of the DSM-5, which could be viewed as either an advantage or disadvantage, is to appropriately bill insurance companies for the psychological services you receive. My cynical mind says that the main purpose of the DSM-5 is to bill insurance companies. Admitting that opens me to an onslaught of criticism, but the notion is difficult to ignore from time to time. My optimistic mind asserts that the manual’s primary objective is to determine the appropriate starting point for treatment by offering shared language amongst the psychiatric community and relevant, empirically supported treatments in order to best help those afflicted by psychological pain. Some of the low stars engender from disagreements and discontent with the actual changes that have been made to the DSM. Which then leads to the next question: What’s new? And a question I always like to consider when people are in an uproar: Does it matter? I summarized the types of changes made to the new Diagnostic and Statistical Manual below. The list I include is by no means exhaustive. Furthermore, I offer a few reasons for specific changes. Most changes reflect the current body of psychological research and the clinical experiences of mental health professionals who maintain specific areas of expertise. Some changes were made to clarify esoteric and/or confusing terminology. Other changes were intended to further minimize stigma. As a consumer of mental health services, these changes may mean very little or very much to you. I invite you to ask yourself the following questions:

Would it matter if my current diagnosis now has a different name?

Would it matter if I no longer met criteria for a diagnosis with which I used to identify?

Would it matter if my current diagnosis was eliminated from the DSM-5; if so, what would now explain my current set of problems?

Do I now qualify for a “mental disorder” when I didn’t before? How is this relevant to my life?

Would it matter if my current diagnosis is unchanged by the new DSM?

Answering these questions may help determine whether the new Diagnostic and Statistical Manual has any bearing on your life. If you are interested in knowing some of the changes, read onward. If not, consider the notion of labels as discussed in this entry. Do labels act as your chains or do they help you move toward a better life?

Changes to the DSM

There have been many changes to the Diagnostic and Statistical Manual. Below are what I have found to be the major categories of change along with some examples. This list is not exhaustive. For a more extensive understanding of all the changes made to the DSM, consult the reference list at the bottom of this blog entry. Re-Terming Existing Diagnoses New terms have been created to replace old diagnoses. For instance:

* NOS stands for Not Otherwise SpecifiedNew Criteria, Specifiers, Etc. Many diagnoses have maintained the same terms, but the criteria have change or new specifiers have been added. For example:

The diagnostic criterion for attention-deficit/hyperactivity disorder (ADHD) that previously required onset of clinical impairment to occur before age 7 has changed to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12.

A mental health practitioner must specify if a person with Bipolar I Disorder also experiences “anxious distress” to indicate whether severe levels of anxiety co-occur with symptoms of mania or depression.

New Diagnoses Some experiences that were once considered symptoms of another disorder have been extracted to represent a completely new disorder. For instance:

Disruptive Mood Dysregulation Disorder is included for children under the age of 18 who exhibit symptoms comparable to Bipolar Disorder to avoid the over- and often misdiagnosis of Bipolar Disorder in children.

Premenstrual Dysphoric Disorder has been added.

The Sleep-Wake Disorders category includes a number of new diagnoses to highlight specific sleep-wake problems that are not due to an already existing medical or mental disorder (i.e., Breathing-Related Sleep Disorders, Circadian Rhythm Sleep-Wake Disorder, etc.).

Gender Dysphoria captures those who experience a marked incongruence between one’s experienced/expressed gender and assigned gender. Not only is it a new diagnosis, but a new class and considered separate from sexual dysfunctions and paraphilia. The new classification emphasizes the internal sense of gender incongruence over the overt gender identification.

Gambling Disorder is now specifically listed as a diagnosis.

Elimination Certain subtypes, disorders, and symptoms have been completely eliminated from the DSM. For example:

A person with Schizophrenia will no longer being given a subtype of paranoid, disorganized, catatonic, undifferentiated, or residual.

To meet criteria for Acute Stress Disorder and Posttraumatic Stress Disorder (PTSD), a person no longer has to feel intense fear, helplessness, or horror when the traumatic event occurred. (Given the fact that many people shut off emotionally or become angry when a trauma occurs, this was likely a good elimintation!)

Somatization Disorder, Hypochondriasis, Pain Disorder, and Undifferentiated Somatoform Disorder have been removed and are all considered part of Somatic Symptom and Related Disorders.

Minor Changes to Criteria Needed to Meet a Given Disorder

Honestly, there are many of these changes and they are likely only of interest to mental health practitioners. If you are curious about a specific disorder, it would be best to pick up a DSM-5 and compare it to the DSM-IV-TR to see if the specific criteria have changed. For example:

PTSD now has 4 symptoms-clusters instead of 3 symptom-clusters; one of the previous 3 clusters (avoidance/numbing) was divided into 2 distinct clusters: avoidance AND numbing.

The criteria for Dissociative Identity Disorder have changed to include either self-reported or observed identity disruption.

Pica and Rumination Disorder criteria have been revised to increase clarity and indicated that these disorders can occur at any age.

Anorexia Nervosa no longer requires amenorrhea.

Criteria for Oppositional Defiant Disorder have been refined to create new groupings of symptoms, eliminate exclusion criteria, identify ways to distinguish “oppositional” behavior from “normal” behavior, and specify severity ratings.

What About All that Stuff I Read about Reconceptualizing Personality Disorders? In all of the trainings I completed on the upcoming DSM-5, I found the most exciting changes to relate to personality disorders. It appears further research is needed to transition to reconceptionalized personality disorders. Consequently, personality disorders retain their diagnostic criteria and then the DSM-5 offers an alternative model for further study. It is worth a look, if you are interested in learning more about the new model! Further Reading American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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Dr. Bridgett Ross is a Licensed Clinical Psychologist and owner of Ross Psychology.

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